Doctors Restore Some Hand Function to Quadriplegic Patient

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TUESDAY, May
15, 2012 (HealthDay News) — For the first time,
surgeons have restored partial mobility to the hand of a quadriplegic patient.

The patient had suffered an
injury to the lowest bone in his neck, and it was the specific location of the
injury that allowed surgeons to avoid operating on the spine itself.

Instead, the team focused
on the patient's still healthy upper arm nerves. Bypassing the hand's original (and now
damaged) connection to the injured spine, the team effectively used the upper
arm nerves to rewire a fresh connection to the intact motor control region of
his brain.

A year of rigorous physical
therapy later, the team of surgeons at Washington University School of Medicine
in St. Louis reaped their reward: the restoration of the patient's ability to
flex his thumb and index finger.

"This procedure is
unusual for treating quadriplegia because we do not attempt to go back into the
spinal cord where the injury is," surgeon Dr. Ida K. Fox, an assistant
professor of plastic and reconstructive surgery, said in a news release from
the university. "Instead, we go out to where we know things work —
in this case the elbow — so that we can borrow nerves there and
reroute them to give hand function."

Fox and her colleagues
discuss the case in the May 15 online issue of the Journal of
Neurosurgery.

The authors pointed out
that their surgical approach would only be viable for patients like theirs:
namely, those who sustain injury to the C7 (or C6) vertebra, located in the
lower region of the neck. While such patients lose hand
function, they retain function in their shoulder, elbow and wrist
because the spinal region above the injury remains free of damage.

Those who suffer an injury
to the C1 through C5 vertebra experience total arm function loss, and would not
be eligible for this type of nerve bypass surgery, developed and performed by
study senior author Dr. Susan E. Mackinnon, chief of the university's division
of plastic and reconstructive surgery.

Mackinnon's initial goal
had been more targeted: to restore thumb and index finger function to patients
suffering from localized nerve damage. This is the first instance in which the
approach was harnessed to overcome damage stemming from spinal cord injury.

The breakthrough, however,
relies heavily on arduous post-surgical physical therapy, during which the
patient's brain must be taught to recognize that the rewired nerves control the
fingers rather than the elbow.

The good news: Any
similarly injured patient with intact upper arm nerves would be eligible for
this procedure, regardless of how much time has elapsed since the initial
spinal cord damage. The current patient was operated on two years after his
accident.

One expert explained why
such surgery might work so long after a spinal cord injury.

"What this case
demonstrated, and what is different from peripheral nerve-injured patients who
undergo nerve grafts and nerve transfers, is that the motor neuron pool is
intact and the muscle is preserved for a longer time than in peripheral nerve
injury," said Dr. Lewis Lane, chief of hand surgery at North Shore
University Hospital in Manhasset, N.Y. "If a peripheral nerve is cut, the
lower motor neuron cell connection to the muscle is disrupted. However, in
spinal cord injury the injury is, by definition, in the spinal cord, so the
connection ... is not disrupted because peripheral nerves are intact.

"This connection is
important for muscle preservation," Lane added, "and is the subtle
but important distinction that allowed the procedure done on the patient in
this case report to succeed more than 22 months after the injury."

The Washington University
surgeons also noted that the procedure stood a good chance of success because
of its simplicity.

"This is not a
particularly expensive or overly complex surgery," Mackinnon said in the
news release. "It's not a hand or a face transplant, for example. It's something we would like other
surgeons around the country to do."

Dr. J. Marc Simard, a
professor of neurosurgery, pathology and physiology at the University of
Maryland School of Medicine in Baltimore, was excited about the success of the
procedure.

"It's very important
to caution that this applies only to those with spinal injuries far enough down
on the spine that there are remnants of nerves that are still functional above
the injury that can be tapped into," he noted.

"But, for these types
of patients, this sounds perfectly reasonable and rational," Simard added,
"based on the basic science work that's been going on for the last 25
years. And [it's] really a major step in the rehabilitation world."

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